08070051 CITY OF CUPERTINO4 °�R,`*� �.:
BUILDING DIVISION PERMIT Q 1�[1V QR �.D QN'4 rt'x
BUIL`fftaT'R UPERTINO RD SAMUEL CONSTRUCTION 08070051
OWNER'S NAME PERMIT BVE DAYS
SUNNY VIEW LUTHERAN HOME 2141 CAROBWOOD LN 07/08/2008
HONE SANITARY No CONTROL NO.
(408) 262-2727
BUILDING PERMR INFO
ARCHRECTIPNGINFt]t: BLDG ELECT PLUMB _
I O a LICENSED CONTRACTORS DECLARATION Job Description
I bucDf
y rom Wt 1 w lid under Provision,,of Chaper 9(aonco
acinr
Nth Section 700M of MvLdon J arihc B.*m and Pmrndora Coda.a dmY llcer.mIs DEMO OLD EXSTNG BLDG, GRG & TRASH ENCLOSURE
Mn full faux uhf cO
ipz 1}c10114772— -
S p ARCHDECI S DECLARATION
u'7S 7 I oMvwd mY plw W11 W urA u PoEllc rearm
ktU
y hd l.icoumd Pmfndow
5 OWNER Bucinpi R front
the CIA'IION
a i 1 bmby+Trim that 1 I.eBud linin tie Cmion Co Ism law for the
3 D o which nr recon ercam TDd I.S.Budin,ad om roalau Code Any city a munry,
S f<i which�uhe,pump m onhmlml de,impure,drmall.h.a mpde m7,lrlaum
iy Prim m is Ltrarae.din imui=me apphiom for inch Pawl to Bk,tlPrci.acct
SSC thole ulica.adpmaantmNcpmiriouofWeCaoruldaI10 law(Chapa9 Sq.Ft.Floor Area Valuation
I-9 lram.a gNm Siem Y0B0)of0i.cumaurine Bim®wPmrmmn axlac $17000
thin he u.pL Liz fr® w me ah,m for ftduyd ompdm Ant'.mlad 1 of
Saamn 7031-1by aM.Mlk t fa o pawl m j M inn applbnt m e cMI pnulry or 3 2 61512 4 Number Occupancy Type
inn mem than Bw hooded whir(SM
❑L u uric of Ne Jrapvry,IX my mFmyer,with wara u rhetrmle®pevutlorL
will Oothewan Cothc he Cwvmtintamdaowdm Wtb(See.IOM,Batl® Required Inspections
w Pmfraimu cmc The Cooeehod.Lloam law ma WtM*m m enc m q p
pm m who pfoaionpaverthe p and Mhodeeramiwh waffemmmnllhhu
owe mPlayea,proNded the aeh impm.mmu m mtman,lnd oroQeo foray B, '
howcwr.tiehdldlq abapropwinu mine did onoyou or®own fo.YoM Of
mime Alit have the hlndm of pmrinr man be dm inn OdW a hoPmw fa Pmpoe of
ale.}
❑1.u a.ma of tion RoRtY.w aeludwlY mna.ciinr Nm Van..d mnauema m
anuuua the pmjca(Sec.7014,Business and Pmfcs ne Coda)The Comianes U-
®M lar dna awl apply b N one of papery who bnBm or Impure ThL'mal.and.
Lincan
0 Isth uu nor nvth pojeW Alm aamvamaD)Oaas:dpm®mmthn Cmlrwor. - - r"
lay.
ED eampuMa Svc .BlPCfa lMa.a,me
Owrc Due
W ORKFHS COMPENSATION DURATION
t
I herby Aim under peaWy W palmy on,rJme tofmwiq dor•-•lo-'
Ilima "lmdnWas CmfOomofCa dMsdf•m,urefa Wmlm'aCmnput
rump,u povi&d for by Section 57W of the Iaha Cam.IN me pafam.oa of tin
vurk for whzh lmr Permit u lined.
1 haw ma will mdnuin Wm s Co opmutmn Inw a.eyWhnd by Statin .
3700 of the labor Cock.for the ciformma of the work ra which this permith Imo.
My Worker'.Compeuatim Iu.wvu¢curio W Pdlry number uc -
6Nec �e+a-(-L F7. vlel P,ItiNd gaej.ozG433
CERTIFICATE OF UEMFTION FROM WORKERS'
COMPENSATION INSURANCE
(Thttacthon mW not he campked U tie pumh Ir foram ho dundmWm(S10W
mica.)
1 citify um w an:per(mmava W the.art fa.him rW gamin u faaed.l duff m
cmpbyanypcm inmymumumumbaamembj=Aft WwaYCampensLUm .
U"or CASOMiL Ora
NOTICE TO A to the P.U.,Ba matinr Wer Axan f of E Labor
Co you maim -
b¢amritb co ct m the Wrd,pr Cmpor ti ImNt nal W the uba Cade.yin nein
�ZO rrwNm mmaW with mai pmWdaa a noir pamb uhaD m amrind a.dmt
Z^ CONSTRUCTION IENOBI()AORNCY -
[-a Ihueby dnna ma there i.,mnan.Non ladinr,ap y forme pofamaaa or
C> the work for which thin gamin il taai(Se 3W7.Ch.C.)
W a Larolerr Nrme
r7 Z LrnmYr Addma .
U Q 1 ratify"1 low rend thin a Ikwion,nd.am tic the More Information u
U.^ cmuect L aper m amply with dl city vW eomry,a®ooa,ud male bin,watinrm
0 huuiinr mwaUm..oa bemby au.hwa rephormurly or thin dry to upon the
abase-mmumnd Popa1Y for iupNon purpowL
(9k)hg m to ave,inmmdry and kwp howca m.Cry of Copnhm Mdaa
r y Ilabllltiq Jmrmonu.emu.nd oprnva wNchmgmanyw.yacmeafpWnaid Ony
U Z in mnwrit, a of ma pmtinr of lhh PemiL
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S44j2zW Date �.
SOURCE RFGULja2n.
Re-roofs
Sipmore of ApoI renaacmr Dau
r DousMATvuALSDlsaohvae Type of Roof
WlB the CupcL rare pdCo&.CpmtaomabdLM FTWdoanucul
u nicahnd by the Cupenim Momcipd Cade.CWpa 9.12 um me Halm W SWay
Conic.Sectim 25532(a)? ,H
Ely. .9N. All roofs shall be inspected prior to any roofing material being installed.
Will ere applient or mina building amapua hon eguiplva a dam wNcb If a roof is installed without first obtaining an inspection,I agree to remove
emit WaaWoa d,cmlmiuna u demN by the Ray Aro Air Owiry Muuro^m all new materials for inspection.
Duma?
❑Ya P(Nu
thaw narl theham nuahmquhcmm.mdmCapw6.95ofinehumn
ma.HcW"SaraYCodq Semaa H5M.73533wWYSSd.lmdashadthmifhhe hild'mr .
dam not cmmly lone a Wine tau it is my mamwb0ity to notify the occupmt W lie
mquiamenu w,hic moat men - rauauc af.CaWlaa of = (` Signature of Applicant Date
��r. ��8 ° All roof coverings to be Class'n¢'or better